Sudden losses and sudden gains during a DBT-PTSD treatment for posttraumatic stress disorder following childhood sexual abuse

Sudden gains in routine clinical care: application of a permutation test for trauma-focused cognitive behavioural therapy

Background: Sudden gains, defined as large and stable improvements of psychopathological symptoms, are a ubiquitous phenomenon in psychotherapy. They have been shown to occur across several clinical contexts and to be associated with better short-term and long-term treatment outcome. However, the approach of sudden gains has been criticized for its tautological character: sudden gains are included in the computation of treatment outcomes, ultimately resulting in a circular conclusion. Furthermore, some authors criticize sudden gains as merely being random fluctuations.Objective: Use of efficient methods to evaluate whether the amount of sudden gains in a given sample lies above chance level.Method: We used permutation tests in a sample of 85 patients with posttraumatic stress disorder (PTSD) treated with trauma-focused cognitive behaviour therapy in routine clinical care. Scores of self-reported PTSD symptom severity were permuted 10.000 times within sessions and between participants to receive a random distribution.Results: Altogether, 18 participants showed a total of 24 sudden gains within the first 20 sessions. The permutation test yielded that the frequency of sudden gains was not beyond chance level. No significant predictors of sudden gains were identified and sudden gains in general were not predictive of treatment outcome. However, subjects with early sudden gains had a significantly lower symptom severity after treatment.Conclusions: Our data suggest that a significant proportion of sudden gains are due to chance. Further research is needed on the differential effects of early and late sudden gains.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Using machine learning to predict sudden gains in intensive treatment for PTSD

Sudden gains have been found in PTSD treatment across samples and treatment modality. Sudden gains have consistently predicted better treatment response, illustrating clear clinical implications, though attempts to identify predictors of sudden gains have produced inconsistent findings. To date, sudden gains have not been examined in intensive PTSD treatment programs (ITPs). This study explored the occurrence of sudden gains in a 3-week and 2-week ITP (n = 465 and n = 235), evaluated the effect of sudden gains on post-treatment and follow-up PTSD severity while controlling for overall change, and used three machine learning algorithms to assess our ability to predict sudden gains. We found 31% and 19% of our respective samples experienced a sudden gain during the ITP. In both ITPs, sudden gain status predicted greater PTSD symptom improvement at post-treatment (t2 W=-8.57, t3 W=-14.86, p < .001) and at 3-month follow-up (t2 W=-3.82, t3 W=-5.32, p < .001). However, the effect for follow-up was no longer significant after controlling for total symptom reduction across the ITP (t2 W=-1.59, t3 W=-0.32, p > .05). Our ability to predict sudden gains was poor (AUC <.7) across all three machine learning algorithms. These findings demonstrate that sudden gains can be detected in intensive treatment for PTSD, though their implications for treatment outcomes may be limited. Moreover, despite the use of three machine-learning methods across two fairly large clinical samples, we were still unable to identify variables that accurately predict whether an individual will experience a sudden gain during treatment. Implications for clinical application of these findings and for future studies are discussed.

Sudden gains in PTSD symptoms and social functioning in cognitive processing therapy for posttraumatic stress disorder

OBJECTIVE

Sudden gains (SGs) are rapid symptom improvements between two consecutive therapy sessions that predict treatment outcomes. This study investigated SGs in posttraumatic stress disorder (PTSD) symptoms, interpersonal relationship functioning, and social role functioning in Cognitive Processing Therapy (CPT).

METHOD

Participants were 121 patients and 81 therapists involved in a parent randomized controlled hybrid implementation-effectiveness trial of CPT. Descriptive analyses examined the frequency and timing of different forms of SGs. Multilevel modeling examined the impact of the three SGs on outcomes.

RESULTS

PTSD SGs occurred more often and at different sessions than SGs in facets of social functioning. Most individuals experienced only one form of SG and there were no significant clinical or demographic differences in those who had PTSD only SGs, social functioning only SGs, or both SGs. PTSD SGs and interpersonal relationship functioning SGs both predicted changes in PTSD symptoms and interpersonal difficulties over time, but not changes in social role functioning. SGs in social role functioning predicted all three forms of outcomes.

CONCLUSIONS

The findings suggest that there are multiple forms of SGs in CPT beyond primary symptom changes that are predictive of patient outcomes. Clinicians should highlight various SGs that patients experience to further enhance outcomes.

Efficacy and Risk Factor Analysis of DBT Therapy for PTSD-Related Symptoms in Mainland Chinese College Students Based on Data Mining

Posttraumatic stress disorder (PTSD) is a mental disorder characterized by a delayed onset and long-lasting psychiatric disorder in an individual due to unusual threatening or catastrophic stressful events, characterized by repeated experiences of the situation, avoidant behaviors, emotional numbness, hypervigilance, and other mental symptoms. It seriously affects the occupational, psychological, and social functions of the human body, leads to a decrease in the quality of life, and brings a greater economic burden to the patients themselves, their families, and the society. It has attracted widespread attention worldwide. Due to social transformation and fierce competition, college students are increasingly exposed to various stressful or traumatic events, and PTSD is becoming more and more obvious. Therefore, this study took a university student as the research object, analyzed the risk factors of PTSD, and used the method of data mining to analyze the effectiveness of DBT therapy and completed the following work: (1) this paper introduces the research status of PTSD pathogenesis at home and abroad and expounds the treatment methods and research results of DBT. (2) The basic principle of BPNN is introduced, the weight and threshold of BPNN are screened by genetic algorithm, and the best weight and threshold after screening are given to BPNN. A GA-BP model is constructed to improve the learning quality of BPNN. (3) The optimal parameters of the model are selected through experiments, and the model is verified by the collected data. The results show that the model has superiority in evaluating the effectiveness of DBT therapy. Then, it was proved by experiments that DBT therapy has a good effect in the treatment of PTSD. Finally, the influencing factors of PTSD were analyzed one by one through the experimental results.

Measurement-Based and Data-Informed Psychological Therapy

Outcome measurement in the field of psychotherapy has developed considerably in the last decade. This review discusses key issues related to outcome measurement, modeling, and implementation of data-informed and measurement-based psychological therapy. First, an overview is provided, covering the rationale of outcome measurement by acknowledging some of the limitations of clinical judgment. Second, different models of outcome measurement are discussed, including pre-post, session-by-session, and higher-resolution intensive outcome assessments. Third, important concepts related to modeling patterns of change are addressed, including early response, dose-response, and nonlinear change. Furthermore, rational and empirical decision tools are discussed as the foundation for measurement-based therapy. Fourth, examples of clinical applications are presented, which show great promise to support the personalization of therapy and to prevent treatment failure. Finally, we build on continuous outcome measurement as the basis for a broader understanding of clinical concepts and data-driven clinical practice in the future. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Using machine-learning to predict sudden gains in treatment for major depressive disorder

OBJECTIVE

Sudden gains during psychotherapy have been found to consistently predict treatment outcome but evidence on predictors of sudden gains has been equivocal. To address this gap, the present study utilized three machine learning algorithms to predict sudden gains during treatment for major depressive disorder.

METHOD

We examined predictors of sudden gains in two large samples of individuals receiving treatment in a partial hospital setting (n = 726 and n = 788; total N = 1514). Predictors included age, gender, marital status, education, employment status, previous hospitalization, comorbid diagnoses, and pretreatment measures of depressive and generalized anxiety symptoms. We used three machine learning models: a Random Forest model, a Random Forest model with an adaptive boosting meta-algorithm, and a Support Vector Machine model.

RESULTS

In both samples, sudden gains were identified and found to significantly predict outcome. However, none of the machine learning algorithms was able to identify robust predictors of sudden gains. Thus, even though some models achieved fair prediction of sudden gains in the training subset, prediction in the test subset was poor.

CONCLUSIONS

Despite the use of a large sample and three machine-learning models, we were unable to identify robust demographic and pretreatment clinical predictors of sudden gains. Implications for clinical decision making and future studies are discussed.

A Revised Theory of Sudden Gains in Psychological Treatments

Sudden gains were first defined and quantified by Tang and DeRubeis (1999) and were found to predict treatment outcome in cognitive therapy for depression. Since that seminal paper, over 100 examinations of sudden gains have been published and sudden gains have been found to be ubiquitous in psychological treatments and to consistently predict better treatment outcomes across a multitude of disorders and contexts (see Shalom & Aderka, 2020 for a review). The research on sudden gains has seen considerable growth over the past 20 years. However, the theory behind sudden gains (which addresses processes leading to sudden gains, and processes resulting from sudden gains) has never been revised. Based on the empirical research which has accrued over the last 20 years, we present an empirically-based revision of the theory of sudden gains. The revised theory addresses both predictors of sudden gains and processes that may lead to sudden gains, as well as the consequences of sudden gains and the processes by which sudden gains can affect outcome. We also present a number of hypotheses that can be derived from the theory as well as the status of empirical evidence supporting these hypotheses. Research and clinical implications are discussed.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

suddengains: An R package to identify sudden gains in longitudinal data

Sudden gains are large and stable improvements in an outcome variable between consecutive measurements, for example during a psychological intervention with multiple assessments. Researching these occurrences could help understand individual change processes in longitudinal data. Three criteria are generally used to identify sudden gains in psychological interventions. However, applying these criteria can be time consuming and prone to errors if not fully automated. Adaptations to these criteria and methodological decisions such as how multiple gains are handled vary across studies and are reported with different levels of detail. These problems limit the comparability of individual studies and make it hard to understand or replicate the exact methods used. The R package suddengains provides a set of tools to facilitate sudden gains research. This article illustrates how to use the package to identify sudden gains or sudden losses and how to extract descriptive statistics as well as exportable data files for further analysis. It also outlines how these analyses can be customised to apply adaptations of the standard criteria. The suddengains package therefore offers significant scope to improve the efficiency, reporting, and reproducibility of sudden gains research.

Cognitive processes associated with sudden gains in cognitive therapy for posttraumatic stress disorder in routine care

Objective: Although most studies investigating sudden gains in treatments for posttraumatic stress disorder (PTSD) report a positive association between sudden gains and outcomes at the end of treatment, less is known about sudden gains in routine clinical care and the processes involved in their occurrence. This study investigated changes in cognitive factors (negative appraisals, trauma memory characteristics) before, during, and after sudden gains in PTSD symptom severity. Method: Two samples (N₁ = 248, N₂ = 234) of patients who received trauma-focused cognitive therapy for PTSD in routine clinical care were analyzed. Mahalanobis distance matching, including the propensity score, was used to compare patients with sudden gains and similar patients without sudden gains. Estimates from both samples were meta-analyzed to obtain pooled effects. Results: Patients with sudden gains (n₁ = 76, n₂ = 87) reported better treatment outcomes in PTSD symptom severity, depression, and anxiety at the end of therapy and follow-up than those without sudden gains. No baseline predictors of sudden gains could be reliably identified. During sudden gains, those with sudden gains had greater changes in both cognitive factors than matched patients. Meta-analyses of the two samples showed that negative appraisals had already decreased in the session prior to sudden gains compared with matched patients. Conclusions: The pooled estimates suggest that changes in negative trauma-related appraisals precede sudden gains in PTSD symptoms. The results suggest that interventions that promote change in appraisals may also facilitate sudden gains in therapy.

This study highlights that a substantial subgroup of patients with PTSD showed concurrent large improvements in PTSD, appraisals, and memory features from one treatment session to the next. Sudden gains were also preceded by greater changes in appraisals than sessions that did not include sudden gains. This supports interventions that target the identification and modification of negative appraisals in PTSD, which, if successful, can result in sudden symptom improvements that are associated with better treatment outcomes.

Mechanisms of change in psychological interventions for posttraumatic stress symptoms: A systematic review with recommendations

Psychological interventions can alleviate posttraumatic stress symptoms (PTSS). However, further development of treatment approaches calls for understanding the mechanisms of change through which diverse interventions affect PTSS. We systematically searched the literature for controlled studies of mechanisms of change in psychological interventions for PTSS. We aimed to detect all empirically studied mechanisms and evaluate the level of evidence for their role in the alleviation of PTSS. We identified 34 studies, of which nine were among children. We found evidence for improvements in maladaptive posttraumatic cognitions as a general mechanism of change involved in diverse interventions, among both adults and children. We also found some preliminary evidence for increases in mindfulness as a mechanism of change in mindfulness- and spiritually-oriented interventions among adults. We found scant, mixed empirical evidence for other mechanisms of change. Notably, studies on changes in traumatic memories as a mechanism of change were lacking, despite clinical emphasis on their importance. A major limitation across reviewed studies was that most could not establish temporal order of changes in mechanisms and PTSS. Including thorough analyses of mechanisms of change beyond cognitions in all future trials and improving the reporting of findings would aid the development and implementation of even more effective interventions.

An exploratory study of patients' sudden losses during outpatient CBT and therapists' experience of difficulties

OBJECTIVE

Patients' sudden deterioration in symptomatology, also called sudden losses, is a rarely explored phenomenon.

METHOD

Psychological distress of 1,763 patients treated by 140 therapists was monitored after every therapy session. Patient-reported outcome measures and patients' therapy satisfaction was assessed. Therapists rated their experience of difficulties for every patient repeatedly over the course of therapy.

RESULTS

More than one-quarter of patients (26.5%) experienced at least one sudden loss during therapy. Patients with sudden losses did not differ significantly in psychotherapy outcome and therapy satisfaction from patients without sudden shifts. Therapists did not experience professional self-doubt more often when working with sudden loss patients.

CONCLUSION

Sudden losses were not necessarily harmful for the outcome of psychotherapy and patients' global therapy satisfaction. The results suggest that sudden losses can be compensated over the course of treatment.

Trauma-related emotions and radical acceptance in dialectical behavior therapy for posttraumatic stress disorder after childhood sexual abuse

BACKGROUND

Posttraumatic Stress Disorder (PTSD) related to childhood sexual abuse (CSA) is often associated with a wide range of trauma-related aversive emotions such as fear, disgust, sadness, shame, guilt, and anger. Intense experience of aversive emotions in particular has been linked to higher psychopathology in trauma survivors. Most established psychosocial treatments aim to reduce avoidance of trauma-related memories and associated emotions. Interventions based on Dialectical Behavior Therapy (DBT) also foster radical acceptance of the traumatic event.

METHODS

This study compares individual ratings of trauma-related emotions and radical acceptance between the start and the end of DBT for PTSD (DBT-PTSD) related to CSA. We expected a decrease in trauma-related emotions and an increase in acceptance. In addition, we tested whether therapy response according to the Clinician Administered PTSD-Scale (CAPS) for the DSM-IV was associated with changes in trauma-related emotions and acceptance. The data was collected within a randomized controlled trial testing the efficacy of DBT-PTSD, and a subsample of 23 women was included in this secondary data analysis.

RESULTS

In a multilevel model, shame, guilt, disgust, distress, and fear decreased significantly from the start to the end of the therapy whereas radical acceptance increased. Therapy response measured with the CAPS was associated with change in trauma-related emotions.

CONCLUSIONS

Trauma-related emotions and radical acceptance showed significant changes from the start to the end of DBT-PTSD. Future studies with larger sample sizes and control group designs are needed to test whether these changes are due to the treatment.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT00481000.

Adversity, attachment, and mentalizing

The papers in this special issue offer evidence of personality disorder as a dysfunction of higher-order cognition, which is conceptualized variously as a disorder of mentalizing, metacognition, mindfulness, social cognition and reflective function. While there may be differences in the scope of these concepts, they all imply that higher-order mental processing is at the core of personality function. In this commentary, the authors use mentalizing as an umbrella term for these concepts, and argue that it is the complex interaction of adversity, attachment and mentalizing that leads to the characteristic symptoms of borderline personality disorder and other personality disorders. Evidence is provided from the papers in this special issue, comments made on the findings and further avenues for research are recommended.